You will need the following information:
Name of patient: ______________________________ Patient’s date of birth:____________________ Identification # (found on the insurance card):_________________ Insurance company phone number (usually found on the front of the insurance card)
Call Insurance Provider and ask the following questions:
Are my benefits for a calendar year or benefit year?
If benefit year, ask for the dates:____________________________________
(Example: 07/01/08 through 06/30/09)
Is there any pre-authorization required?
If so, who do I call? _____________________________________________
DoES my insurance cover:
1. Spinal Manipulation – Code 98941 Yes or No
What is the coverage: Is there a maximum number of visits? If so, how many?_____
Is there a deductible? If so,how much?______
Has any of the deductible been met? _____ If there is a deductible, what percentage will the
company pay versus myself ______________ (Example: 80% company / 20% patient)
Is there an Out of Pocket maximum? If so, what?___________
After this amount, the company will usually pay at 100%
Or instead of a deductible is there a co-pay? If so, what? _______
Is there a maximum dollar amount that the company pays per year? If so, what? ______
2. Therapy – Codes 97012, 97140, 97110
What is the coverage: Is there a maximum number of visits? If so, how many?_____
Is there a deductible? If so,how much?______
Has any of the deductible been met? _____ If there is a deductible, what percentage will the
company pay versus myself ______________ (Example: 80% company / 20% patient)
Is there an Out of Pocket maximum? If so, what?___________
After this amount, the company will usually pay at 100%
Or instead of a deductible is there a co-pay? If so, what? _______
Is there a maximum dollar amount that the company pays per year? If so, what? ______
3. Office visits – Codes 99203, 99213, 99214
What is the coverage: Is there a maximum number of visits? If so, how many?_____
Is there a deductible? If so,how much?______
Has any of the deductible been met? _____ If there is a deductible, what percentage will the
company pay versus myself ______________ (Example: 80% company / 20% patient)
Is there an Out of Pocket maximum? If so, what?___________
After this amount, the company will usually pay at 100%
Or instead of a deductible is there a co-pay? If so, what? _______
Is there a maximum dollar amount that the company pays per year? If so, what? ______
4. X-rays – Codes 72050, 72020, 72100, 72040
What is the coverage: Is there a maximum number of visits? If so, how many?_____
Is there a deductible? If so,how much?______
Has any of the deductible been met? _____ If there is a deductible, what percentage will the
company pay versus myself ______________ (Example: 80% company / 20% patient)
Is there an Out of Pocket maximum? If so, what?___________
After this amount, the company will usually pay at 100%
Or instead of a deductible is there a co-pay? If so, what? _______
Is there a maximum dollar amount that the company pays per year? If so, what? ______
5. Durable Medical Equipment – Codes A9300, E0190
What is the coverage: Is there a maximum number of visits? If so, how many?_____
Is there a deductible? If so,how much?______
Has any of the deductible been met? _____ If there is a deductible, what percentage will the
company pay versus myself ______________ (Example: 80% company / 20% patient)
Is there an Out of Pocket maximum? If so, what?___________
After this amount, the company will usually pay at 100%
Or instead of a deductible is there a co-pay? If so, what? _______
Is there a maximum dollar amount that the company pays per year? If so, what? ______
6. The patient will be having multiple treatments; 2-3 times per day Will the company pay on the multiple treatments?
1 week Intensive Care
Available for patients with spinal curvatures 0-25º 98941 – 14 units 97012 – 40 units 97140 – 14 units 97110 – 36 units 99203 – 1 unit 99213 – 2 units 72040 – 1 unit 72050 – 1 unit 72020 – 2 units 72100 – 1 unit 72069 – 2 units
Equipment codes A9300 E0190
2 week Intensive Care
Available for patients with spinal curvatures >25º 98941 – 30 units 97012 – 74 units 97140 – 28 units 97110 – 76 units 99203 – 1 unit 99213 – 2 units 72050 – 1 unit 72020 – 3 units 72100 – 1 unit 72069 – 2 units 72040 – 2 units
Equipment codes A9300 E0190 99070 (scoliosis traction chair)
42 visit Expanded Care
Available for patients with any amount of spinal curvature 98941 – 42 units 97012 – 42 units 97140 – 42 units 97110 – 84 units 99203 – 1 unit 99213 – 3 units 72050 – 1 unit 72020 – 3 units 72100 – 1 unit 72069 – 2 units 72040 – 2 units
Equipment codes A9300 E0190 |